By Abhinav Shashank, co-founder and CEO, Innovaccer.
Abhinav Shashank
While healthcare leaders uniformly agree that transitioning to value is the way healthcare is going to be in the coming days, it is unclear to most how they can make the transition without negatively impacting their cost outcomes. In an industry which had primarily been fee-for-service based, healthcare organizations are facing immense pressure to innovate and adapt or risk their long-term viability.
In developing strategies to succeed with these trends, many healthcare leaders are realizing that Medicare Advantage (MA) is a key component to their long-term success. The Centers for Medicare and Medicaid Services (CMS) has projected that Medicare Advantage enrollment will reach an “all-time high” in 2019 with 22.6 million Medicare beneficiaries, given the unprecedented growth. And industry analysts like L.E.K. Consulting say that Medicare Advantage enrollment will rise to 38 million, or 50 percent market penetration by the end of 2025.
Going along the same lines of ensuring long-term success and enhanced patient satisfaction, CMS rates Medicare Advantage plans by giving them Star Ratings which help beneficiaries and their family members make informed decisions. As MA Star Ratings become the most visible mark of success, the only trail of thoughts would be: How to improve these Star Ratings?
How do Star Ratings work?
The Medicare Star Ratings are key measures of the quality of care a health plan provides. The health plans are rated on 45 measures categorized under five categories which portray how a health plan takes care of its beneficiaries.
Needless to say, there’s a lot at stake here. The more Stars a health plan has, the more likely they are to attract beneficiaries. But earning top ratings is a difficult task. Payers that wish to reap the benefits of high Star Ratings also need to deliver impeccable care to their members and ensure a satisfactory experience of care.
What holds MA Plans back from achieving better Star Ratings?
A majority of these measures are defined on the basis of specific service received, claims, or clinical information that verifies access and delivery of care. For example, if there is a large number of members that have a chronic disease, plans can pinpoint them and identify the specific care they have received during the year. After that, they can plan targeted interventions to close the gaps and be on the path to deliver positive outcomes.
However, with limited actionable member data available, MA plans just end up focusing on broad, general interventions as compared to undertaking a member-specific, targeted approach. MA plans require timely and detailed information about their members’ health to create interventions that have a lasting impact.
Additionally, it’s important to realize that beneficiaries don’t just have high-quality care, but also have quick access to healthcare service. MA plans need to ensure that the quality of care is always upheld. In most cases, it stems out of efficient collaboration between the clinical staff and healthcare technology.
More importantly, improvements in Star Ratings depend significantly on how engaged a patient is. For example, measures which are related to medication adherence are almost completely hinged on strong patient engagement that makes it easier for patients to get access to their medications and take them on time. In other words, MA Plans need to deploy efforts that are aimed at implementing holistic strategies to address patient needs.
What causes two patients of the same age and with the same disease but from different regions to respond differently to a certain treatment? Even if these two patients appeared similar on paper, their lifestyles are very likely to differ — socioeconomic status, gender, race, ethnicity, family structure and education.
Is SDOH a promise for a better future, or is it just another hype?
Success in the value-based care environment cannot be achieved based solely on clinical insights. According to one study, clinical care accounts for only 20 percent of the health outcomes of patients, while health behaviors, social and economic factors, and physical environment combined add up to in?uence the remaining 80 percent of health outcomes.
Social determinants matter because they can affect the health of the population residing in a particular region for better or for worse. Trying to improve population health armed with only clinical data and not the non-clinical factors, is like investing in a project which cannot generate positive returns.
Although multiple pieces of research demonstrate that social determinants may substantially contribute to a person’s health status and well-being, the major problems are these:
How do we address these complex challenges?
Who is the best-positioned stakeholder to do so in a clinical environment?
What is the right way to address these social determinants?
The Centers for Disease Control and Prevention (CDC) has defined an algorithm to estimate the Social Vulnerability Index (SVI) for every census-tract in the US. However, this algorithm is based on a simple summation of the percentile ranks for all SDOHs, which results in an over-estimation of social vulnerability in cases of high positive correlation between multiple SDOHs.
Working with SDOH data requires a more drilled-down approach and the use of predictive analytics to accurately measure the at-risk population and to advance preventive care methods in an ecosystem.
The right approach is to start from a state-level analysis and drill down to the zip code-level. The effects of social determinants vary in accordance with a very small region. There is a high possibility that all the zip codes in a county will have different susceptibility to a particular social determinant.
What new ways can a revolutionary approach to SDOH open for healthcare?
Every social determinant affects the region in its own way and corresponding preventive actions need to be taken in order to overcome the adverse health outcomes of the citizens of that region. For instance, community resources and data needs to be integrated into the care coordination processes to make proper interventions. When providers are able to completely understand the effects of non-clinical factors, they can provide much better care to their patients.
The analysis of social determinants can be applied for multiple use cases such as:
Identifying the role of behavioral health, social workers and health coaches
Increasing the efficiency of the care coordination team
Forging better partnerships with community resources and social improvement funding agencies, and many more.
The road ahead
Though providers have recognized that social factors significantly influence their patients’ health, they are often unaware of their patients’ social vulnerabilities and are unable to accept responsibility for managing these issues or providing support to their patients outside of the clinical realm. We are stepping into the age of predicting and preventing diseases instead of curing them. That was the traditional approach. With non-clinical data and resources such as SDOH, we can change the future of US healthcare. All we need is the will to right these wrongs.
The reality is that very few people are doing great things with SDoH at this point. A lot of vendors and providers are thinking and talking about SDoH, but many of them don’t yet understand which social determinants are relevant or what to do about them. While the area is too new to boast a list of best practices, an introduction and discussion to the topic might be helpful for those considering a foray into SDoH.
What are SDoH?
The Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, defines SDoH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
If you think that sounds broad, you’re absolutely right. These determinants cover everything from how clean your water is to what your friends are like. The factors are innumerable. Stakeholders estimate that only 20 percent of one’s health is based on clinical care received from healthcare providers, with another 20 percent to 30 percent based on genetics and at least 50 percent based on SDoH.
With those assessments in mind, it seems unfair that almost everything related to health is pinned on provider organizations. The healthcare system cannot be the only player. We say that it takes a village to raise a child, and it would take a village to adequately deal with social determinants.
But those working in healthcare can’t just wait for villages to get involved. As the market continues to shift toward value-based reimbursement, health systems, payers, and vendors will be expected to incorporate SDoH into their tools and patient care. A few principles might help these stakeholders to get started.
The beginnings of a SDoH strategy
An organization’s first step in incorporating SDoH into their strategy should be to decide which data is the most important. For example, it probably wouldn’t help a physician to know which university a diabetic patient attended, but it could help a lot to know that the patient orders takeout almost daily because he doesn’t have a car and isn’t within walking distance of a grocery store with healthy options. These are aspects that, one day, may fall under the banner of SDoH.
Once an organization knows which data elements they want, they can determine how to get it. Unfortunately, the regional nature of SDoH data makes creating an excellent database very difficult. This is why we need vendors to keep SDoH on their minds. Providers need their vendor partners to incorporate SDoH data into their EMRs, population health tools, and other platforms. Healthcare organizations can also gather data by conducting assessments on-site or at patients’ homes.
Non-clinical factors can account for up to 80 percent of the health outcomes for patients. Such factors, including socioeconomic conditions, healthy behaviors, and physical environment, may vary drastically for each patient and can significantly impact health outcomes such as poor medication adherence, frequent visits to the ED, and more. Thus, it is essential to consider these factors while creating care plans to ensure that the specific needs of patients are addressed.
Additionally, healthcare’s transition to value-based care is pushing organizations to lead more efficient population health management programs that address every clinical and social need of the population in which they serve. The challenge, however, is that organizations don’t usually have the means to capture the social needs of the patients or address them beyond the four walls of a hospital to ensure that no care gaps remain unplugged.
To help healthcare organizations gain richer insights into social determinants of health (SDOH), Innovaccer Inc. announces the launch of its SDOH Management solution tailored to capture SDOH data and leverage it to deliver enhanced care, powered by its Data Activation Platform.
Innovaccer offers to assist healthcare organizations in a stepwise approach, starting with surveys for patients to complete in order to evaluate their social needs, such as access to food, housing situations, or economic conditions. Additionally, Innovaccer’s solution allows care teams to send as many surveys as needed with multiple language support. Based on the answers received from the survey, the solution helps care teams find suitable community resources to assign to the patient from a pre-built national database.
The solution’s AI-assisted closed-loop referral process to community resources enables care teams to ensure patient-centric care, even after an encounter is over. This closed-loop referral process gives physicians and social workers complete visibility into the social needs of their patients, which allows them to refer their patients to the most relevant community resources. In fact, patients are also kept in the loop in such a way that they can track their referrals, give feedback, and coordinate with their providers at any time, all through a single mobile application.
Innovaccer’s primary aim with this solution is to empower physicians and care teams with visibility into the social needs of their patients, right in the moment of care. The solution also triggers automated and real-time alerts to care teams if a patient’s needs are found to be urgent, such as high social risk or missed follow up. Additionally, the insights from the survey are available to the physicians right at the point of care within their EHR workflows, ensuring that they have a holistic picture of their patients.
“For organizations under value-based contracts, establishing a culture of wellness is a priority to keep their business model financially viable. Social determinants of health are a gamechanger in this regard and organizations who leverage them put themselves in the driver’s seat,” said Abhinav Shashank, CEO at Innovaccer. “We hope that our solution is instrumental to healthcare organizations as they tie their efforts to address social determinants of health and create similar strategies to maximize care and cost outcomes.”
Only recently, Innovaccer also launched its first-ever in-house research authored by Dr. David Nace, CMO at Innovaccer, around the social vulnerabilities of the population across the US. The research paper named “From Myth to Reality- Revolutionizing Healthcare with Augmented Intelligence and Social Determinants of Health” discusses a revolutionary way of leveraging advanced algorithms to determine the social vulnerability of the zip code-level population.
To learn more about Innovaccer’s SDOH Management solution, click here.
The HealthCare Executive Group (HCEG), in partnership with Change Healthcare, published the 9th Annual Industry Pulse Research Report. Up to 255 survey respondents, with more than 48 percent being vice presidents or higher in executive leadership, shared their insight on the critical issues, challenges and opportunities ranked by HCEG members on the 2019 HCEG Top 10 list last fall.
The confirmation of the HCEG Top 10 and more detailed insights from the Industry Pulse survey are an invaluable resource for healthcare executives within their own organizations. Healthcare leaders can use this report to engage their management in deeper and more constructive efforts to competitively position themselves in their marketplace and to develop more robust and effective strategic programs.
Ferris Taylor
“We hope the 2019 Annual Industry Pulse Report spurs conversation and action for current stakeholders in adapting much faster to demands of a 21st century healthcare system,” said Ferris Taylor, executive director of HCEG. “If traditional stakeholders aren’t able to transform healthcare, outside parties will.”
Healthcare Amid Continued Uncertainty Reflected in HCEG Top 10 & Industry Pulse
External Market Disruption (#7) entered the HCEG Top 10 list for the first time and is confirmed by the Industry Pulse Report with 32.2 percent of respondents anticipating the greatest impact to be “disrupting current business models.” Whether or not external entrants find healthcare to be more complicated than they thought is yet to be seen.
Payment Reform/Value-Based Payments (#4) has been on the HCEG Top 10 list every year for the last decade. 63.6 percent of the Industry Pulse Report respondents expect it will be three years or more before payments contain both upside and downside risk.
Consumerism (#2), Mobile/Digital Health (#5) and member engagement have ranked high in the HCEG Top 10 for a number of years. This year’s Industry Pulse Report shows the tools and services being used to enhance member/patient engagement and the best approaches for addressing passive patients, such as incentives, health literacy and cost transparency tools.
The Data & Analytics (#1) to support multiple healthcare priorities is highlighted this year. Progress in how primary sources of clinical data and analytics have recently been impacting the efficiency and effectiveness of healthcare quality and outcomes are also suggested.
Population Health/Social Determinants of Health (SDoH) (#3) moved higher in the HCEG Top 10 as the industry transitioned from broad medical condition segments of the population to looking at what is called “barriers to better health.” Industry Pulse survey respondents shared how their organizations are integrating SDoH and which non-medical barriers to care their organizations will take action on in the next 12 months. Also noted are anticipated challenges to integrating SDoH into population and clinical care programs.
Privacy/cybersecurity (#10) wasn’t a significant HCEG issue until four or five years ago when a 100 million member records were breached. Industry Pulse indicates that efforts to address cybersecurity threats may be stalling and provides specifics as to reasons. Recently, Modern Healthcare reported that 2 million member records were compromised across 31 different breaches in February 2019 alone — a 500 percent increase over February 2018. This should alarm the industry and HCEG encourages everyone to look at the reasons shared as to why Cybersecurity initiatives are not a higher priority.
Salesforce announces new additions to Salesforce Health Cloud that improve healthcare through connected, intelligent patient engagement. Health Cloud brings CRM to healthcare, enabling providers like Piedmont Healthcare and 180 Health Partners to personalize patient interactions and improve outcomes. With new social determinants of health capabilities, care teams have a complete patient profile, empowering them to connect the care journey and deliver the personalized experiences that patients expect.
“As a not-for-profit, community health system, it is critical that we put the patient experience at the center of everything we do,” said Andrew Chang, executive director of marketing and physician outreach at Piedmont Healthcare. “Salesforce has enabled us to engage with our patients and help them get easier access to care, on their terms, by personalizing how we connect with them and using new ways to book appointments online.”
Introducing Salesforce innovations for healthcare
Salesforce Health Cloud’s new capabilities power complete patient profiles, relevant patient communications, and convenient, connected in-home care, including:
Social Determinants of Health: While medical care continues to improve at a steady pace, that alone cannot address the 80 percent to 90 percent of modifiable contributors to healthy outcomes, such as living conditions, socioeconomic status and environmental factors. These social determinants of health are frequently not identified by care providers, as systems for tracking and surfacing them are siloed in electronic health record (EHR) systems that require manual updates and are difficult to use.
Now care providers can capture critical social determinant information – such as a patient’s transportation options, housing status and care network, and access it in a patient profile – directly within Health Cloud. This gives the provider a more complete view of the critical factors that influence wellness, adherence and outcomes, all on one connected platform.
For example, a care provider that wants to limit a patient’s risk for readmission can know if the patient has access to transportation, or the ability to purchase healthy meals. Similarly, a life science organization that wants to help patients adhere to their therapies or properly use their medical devices can see a patient’s employment status and living arrangements, and thus offer the necessary level of financial and in-home support. A payer organization can deliver personalized preventive or wellness materials to members based on the member’s education or reading level.
By George Mathew, M.D., chief medical officer for the North American Healthcare organization, DXC Technology.
George Mathew, MD
In mid-February, nearly 45,000 health information and technology professionals, clinicians, executives and suppliers gathered to explore healthcare’s latest innovations at the annual Health Information and Management Systems Society (HIMSS) conference in Orlando, Florida.
These “champions of healthcare” examined the greatest challenges facing the industry — including an aging population, chronic disease, a lack of actionable information and increasingly demanding consumers. They also explored how new solutions are being enabled by technologies such as predictive analytics, artificial intelligence (AI), machine learning and telemedicine.
The following four trends drove much of the conversation at HIMSS19 and will continue to shape the next wave of healthcare transformation.
Organizing and innovating around patients
As patients gain access to more information about their health and new technologies empower them to be proactive consumers of healthcare, the industry is focusing on how patients as consumers will drive new models of care. Topics such as patient engagement, patient-centric health information exchanges, personalized care and the consumerization of health were prominent during HIMSS19 learning sessions and conversations around the expo hall.
Non-clinical factors can account for up to 80 percent of the health outcomes for patients. Such factors, including socioeconomic conditions, healthy behaviors, and physical environment, may vary drastically for each patient and can significantly impact health outcomes such as poor medication adherence, frequent visits to the ED, and more. Thus, it is essential to consider these factors while creating care plans to ensure that the specific needs of patients are addressed.
Salesforce announces new additions to Salesforce Health Cloud that improve healthcare through connected, intelligent patient engagement. Health Cloud brings CRM to healthcare, enabling providers like Piedmont Healthcare and 180 Health Partners to personalize patient interactions and improve outcomes. With new social determinants of health capabilities, care teams have a complete patient profile, empowering them to connect the care journey and deliver the personalized experiences that patients expect.